Term
Partial thickness wound
Full thickness wound |
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Definition
-tissue destruction through the epidermis extending into but not thru the dermis
-tissue destruction extending thru the dermis to involve subcutaneoous tissue and possible bone and muscle |
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Term
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Definition
| Non-blanchable erythema of intact skin, individuals with darker skin, discoloration of skin, warmth, edema, induration, or hardness may also be indicators. |
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Term
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Definition
| Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. |
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Term
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Definition
| Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to but not through, underlying fascia. The ulcer presents as a deep crater with or without undermining. |
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Term
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Definition
| Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Undermining and sinus tracts also may be associated with Stage 4 ulcers. |
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Term
| Non-stageable Pressure Ulcer |
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Definition
| A pressure ulcer cannot be accurately staged until the deepest viable tissue layer is visible; this means that wounds covered with eschar and/or slough cannot be staged, and should be documented as non-obervable or non-stageable. |
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Term
Document Size
-Length which direction?
-Width which direction?
-Depth which direction? |
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Definition
-head to toe direction
-hip to hip direction
-measure deepest part of visible wound bed |
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Term
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Definition
| course or pathway that can extend in any direction from the wound, results in dead space |
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Term
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Definition
| tissue destruction underlying intact skin along wound margins |
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Term
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Definition
| a drainage pathway from a deep focus of acute infection through tissue and/or bone to an opening on the surface. |
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Term
| Use what system to document undermining/tunneling/sinus tract? |
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Definition
"clock system" with head 12:00
example 2cm undermining at 3 o'clock |
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Term
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Definition
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Term
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Definition
| thin, watery, pale red to pink |
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Term
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Definition
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Term
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Definition
| thick or thin, opaque tan to yellow |
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Term
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Definition
| thick opaque yellow to green with offensive odor |
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Term
Amount
1.None
2.Scant
3.Small
4.Moderate
5.Large |
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Definition
1.None=wound tissues dry
2.Scant=wound tissues moist, no measurable drainage
3.Small=wound tissues very moist, drainage <25% dressing
4.Moderate=wound tissues wet, drainage involves 25-75% dressing
5.Large=wound tissues filled with fluid involves >75% dressing |
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Term
1.Nonadherent
2.Loosely Adherent
3.Firmly adherent |
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Definition
1.easily seperated from wound base
2.pulls away from wound, but attached to wound base
3.does not pull away from wound |
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Term
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Definition
| usually lighter in color, thinner and stringy in consistency; Color can be yellow, gray, white, green, brown |
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Term
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Definition
| usually darker in color, thicker and hard consistency black or brown in color |
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Term
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Definition
| It is usually beefy red, granular, bubbly in appearence; should be differentiated from a smooth red wound bed; color of tissue red, pink, pale pink or full dusky red |
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Term
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Definition
| can appear as deep pink, then progress to pearly pink/light purple from the edges in full thickness wound or may form islands in the wound base with superficial wounds |
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Term
| Edges? Good condition/ macerated? |
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Definition
| macerated= wet skin from sweat or other outside source around edges so turns white and softens |
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Term
Don't forget
Aspiration
Diarrhea
Nausea
Distension and bloating
dehydration
fluid overload
constipation
gastric rupture
clogged tube
anxiety
dry mouth |
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Definition
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